Compliance and documentation
How to write a mental health treatment plan
Whenever you want to change the goal of your therapy care, or the path you want to take with the client to reach that goal, you’ll want to document a treatment plan.
December 21, 2023 • Updated on October 16, 2025
13 min read
A treatment plan is like a map: If your diagnosis is a reflection of where the client is today, the treatment plan outlines the route to their destination (or goal).
One important thing to remember about treatment plans is that they can change as your client’s needs evolve and change. For example, you might have a plan to treat your client’s depression — but if they start a new job and begin to present more anxiety instead, you may need to change your course of treatment.
Whenever you want to change the goal of your therapy care, or the path you want to take with the client to reach that goal, you’ll want to document a treatment plan.
Key takeaways
- A treatment plan serves as your blueprint for working with a particular client. Working together, you and your client will lay out the approaches you’ll use to reach certain objectives, based on your client’s diagnosis, symptoms, and goals.
- Treatment plans should work in tandem with other documentation (like your intake note and progress notes); include key details, such as the client’s diagnosis and background; and be updated regularly to reflect changing symptoms or progress.
What is a treatment plan?
The purpose of a treatment plan is to understand our client’s areas of struggle, and to collaboratively guide patients towards their mental health goals. It’s typically completed within your first few sessions with a client.
Treatment plans are not just an insurance requirement, they’re the glue to the entire therapeutic process. You’ll cite the goals and objectives from your treatment plan in the progress notes you document after each session.
How often should I update a treatment plan for my client?
You can document a new treatment plan anytime your goals with the client change. But a good rule of thumb is to address or update your treatment plan every 3 to 6 months, in collaboration with your client.
If you're a psychiatrist or nurse practitioner seeing a client for therapy alone, you are required to complete a treatment plan at least twice a year.
3 essential types of clinical documentation
A complete patient chart contains three core pieces of clinical documentation: an intake assessment, treatment plan, and progress notes.
Think of these as the “golden thread”: Your intake note should inform your treatment plan, and your treatment plan goals and objectives should be reflected in each progress note.
Here are the key details of the different types of documentation:
1. An intake assessment (intake note) should be created when initiating a treatment relationship with a client, and serve to document their current state and past experiences with mental healthcare.
2. A treatment plan establishes objectives and monitors progress. The plan includes a diagnosis and clearly establishes medical necessity for treatment.
3. Progress notes should demonstrate a clear and comprehensive story of the client’s progress through treatment. Clear continuity of care is important — each note should lead into the next but also stand alone.
Clinical documentation is a staple of any mental healthcare practice — it’s used to clarify the purpose of your sessions, justify the billing code used, and demonstrate a good picture of the patient’s current mental state.
These standards are outlined by the American Medical Association (AMA), Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), commercial insurers, and other regulatory agencies.
Your license or a particular insurer may have even stricter requirements than those set forth here.
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6 treatment plan requirements
In order to fulfill the needs of insurance carriers, it’s important that your treatment plan documentation contains the following requirements:
1. Session details
These easy-to-note facts are required for all documentation, including your treatment plan:
- Start and stop time
- Place of service: For telehealth sessions, include the client's location (for example: “home” or “office,” as well as a statement that the session was conducted via a HIPAA-compliant audio or visual platform)
- Date of service
- Patient name and a second unique identifier, such as their date of birth or an assigned ID number
- Provider name and credentials
2. Diagnoses
Your entire treatment plan should be built with your client’s diagnosis in mind — so you’ll naturally want to include that diagnosis in the document itself. Specifying your client’s diagnosis also helps establish medical necessity of treatment, which is key for insurance purposes.
This section can include short descriptions of your diagnosis of the patient, such as an ICD-10 code.(Explore our Billing & Coding Resources for more guidance on which code to use.) You may also include past diagnoses, if relevant to present treatment.
3. Brief background
As with any piece of mental health documentation, you’ll want to back up your conclusions with data. In this case, that means documenting your client’s current presenting issues — the symptoms or challenges that prompted them to seek care — to add more background to their diagnosis. For example, if you’ve diagnosed a client with depression, you’d likely also include details about the specific DSM-5-TR symptoms they’re experiencing and how those issues are affecting their daily life and functioning.
4. Recommendation
Next, you should use the background details, diagnosis, and presenting issues that you’ve already described to create a brief statement about your suggested method of treatment. This is where you might detail the therapeutic modality you plan to use, document your ideal session cadence or treatment duration, or include a recommendation for medication.
You can think about this section as the place where you’ll describe a high-level plan for care, which you’ll then support with more detailed goals, objectives, and interventions later in the document.
5. Two or three areas of clinical focus
This is where you detail the goals you have for your patient: How do they want to feel or behave with successful therapeutic intervention? This will likely include elements like:
- A clearly defined goal (including a target date to accomplish it, such as 120 days or 15 visits)
- Action steps or objectives
- Evidence-based modality
You may be more familiar with words like intervention or method — the language isn’t as important as ensuring that there is a goal, an action step, and type of evidence based practice noted in the treatment plan.
Consider using the SMART framework to ensure your goals are compliant with insurance expectations: Your goals should be Specific, Measurable, Achievable, Relevant, and Time-Bound.
Do clients need to sign treatment plans?
A treatment plan should be an agreement between you and your client, so it’s important for both parties to be aware of and consent to the material contained within. But does a client actually need to sign a treatment plan?
It depends. You may be required to secure a client signature under state policy or insurance compliance standards. Even if not required in your specific circumstances, though, getting a client signature is generally considered best practice.
For in-person sessions, providers can ask clients to physically sign their treatment plan. You can also attest that the treatment plan has been reviewed and agreed upon by the client in your note, which is ideal for telehealth sessions.
How do I update a treatment plan?
Updating your treatment plan is pretty simple: You would update the goal, the objective, or the modality — whatever part of the treatment plan needs updating — then sign and date it, and have the patient sign and date it (or verbally agree, see above).
Therapy treatment plan example
Here’s an example of a treatment plan that meets most insurance carriers’ expectations for this type of clinical documentation.
Notice how it contains the recommended session and client details, background on the client’s diagnosis and issues, and SMART goals for treatment.
Client Name: John Public
DOB: 1/1/1991
Age: 32
Date: 1/11/2023
Exact start time and end time: 1:03 pm–1:55 pm: 52 mins
Session location: Serenity Behavioral Health Center, 123 Serenity Street, Hopeville, TX 56789
Diagnosis: (F41.1) Generalized anxiety disorder
Problem 1: Anxiety in Work Settings: John experiences significant anxiety that manifests as racing thoughts, restlessness, and difficulty sleeping. This anxiety has escalated post-COVID pandemic and affects his ability to maintain consistent employment. He describes being "high strung" and suffers from "Sunday Scaries" that can lead to anxiety attacks, impacting his job stability and ability to enjoy free time.
Goal: Within 120 days or 15 therapy sessions, the client will develop skills to manage anxiety effectively, allowing him to maintain employment and enjoy leisure without the need for withdrawal due to anxiety.
Objective 1: Client will demonstrate an increased understanding of ACT principles and apply them to reduce work-related anxiety within 60 days.
- Intervention 1-1: Psychoeducation on ACT principles will be provided, explaining how acceptance, cognitive defusion, being present, self as context, values, and committed action can help manage anxiety. This will include discussing the nature of psychological distress and the role of psychological flexibility in improving mental health.
- Intervention 1-2: Psychological Flexibility Exercises will be conducted to enhance the client's ability to remain adaptable in the face of changing work environments and persist in actions aligned with personal values, even when experiencing anxiety.
Objective 2: Client will learn cognitive restructuring techniques to identify and reframe unhelpful thought patterns related to work within 120 days.
- Intervention 2-1: Cognitive Restructuring will be taught to help the client recognize irrational or unhelpful thoughts that contribute to anxiety. The client will learn to challenge these thoughts and replace them with more realistic and helpful ones, thereby reducing the intensity of anxious feelings.
- Intervention 2-2: Relapse Prevention Planning will be implemented to prepare the client for potential setbacks. Together, we will identify triggers and high-risk situations that may lead to increased anxiety and develop a plan that includes coping strategies and ACT skills to maintain progress.
Client Signature and Date
John Public electronically signed 1/11/23
Clinician Signature and Date
Susan Q. Practitioner, LCSW, 1/10/2023
This document is intended for educational purposes only. Examples are for purposes of illustration only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that the applicable laws and requirements vary from payer to payer and state to state. Please check with your legal counsel or state licensing board for specific requirements.
Is there a billing code for treatment plans?
There is no CPT code associated specifically with treatment plans. If you’re conducting a session with the goal of completing a treatment plan with your client, use the associated time-based therapy code:
For talk therapists:
- CPT code 90834: 45 minutes of psychotherapy, where the total time spent with the patient is 38–52 minutes
- CPT code 90837: 60 minutes of psychotherapy, where the total time spent with the patient is 53–60 minutes
For psychiatry:
- CPT code 99204: 45-minute new patient outpatient visit, where the total time spent with the patient is 45–59 minutes
- CPT code 99205: 60-minute new patient outpatient visit, where the total time spent with the patient is 60–74 minutes
If you’re using a psychotherapy code to bill the session, you also need to document a progress note. Your progress note can share details about how you worked with the client to establish goals and objectives for your treatment plan.
It’s important to use the code that most accurately reflects the time you spent with the patient to treat their condition, and ensure that documentation for the session supports the chosen code.
Documentation of relevant aspects of client care, including documentation of medical necessity, should ideally be completed within 24 hours of visit, and no later than 72 hours.
FAQs on treatment plans
Writing treatment plans eventually becomes second nature, but they can be confusing at first. The answers to these common provider questions may help you get started.
What is the difference between a care plan and a treatment plan?
A treatment plan is usually targeted to a specific issue or diagnosis, while a care plan may be more general and holistic, outlining a broader strategy for achieving well-being. There may be overlap between the two, but a treatment plan is generally more issue-specific than a care plan.
How does the treatment plan align with clinical documentation?
The plan informs progress notes, session content, and discharge summaries. Each session note should connect interventions and client progress to the plan’s objectives.
Who can access a client’s treatment plan?
Access is limited to the client, the provider(s), and — if authorized — insurance reviewers or collaborating clinicians. Plans are part of the client’s protected health record.
Headway makes documentation easy
Headway helps make your practice run smoothly. With a resource library of treatment plan ideas, as well as AI-assisted progress notes and templates designed for compliance, you’ll have access to helpful tools for each session. Connect with a Headway representative to learn more about these tools, and how we can support you with insurance credentialing, billing, claims support, and more.
This content is for general informational and educational purposes only and does not constitute clinical, legal, financial, or professional advice. All decisions should be made at the discretion of the individual or organization, in consultation with qualified clinical, legal, or other appropriate professionals.
© 2025 Therapymatch, Inc. dba Headway. All rights reserved. No part of this publication may be reproduced without permission.
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